Gaps in the Pharmacist’s Pain Management Role

The Current Role of Pharmacists in Pain Care

One of the primary reasons patients visit community pharmacies is to ask for advice about managing pain, signifying chronic pain disease as a notable public healthcare challenge.1,2 Yet, pain is largely undertreated,1 poorly assessed, and managed. Appropriate pain care has been associated with fewer hospital stays and readmissions, faster recovery times, and better quality of life.3 All healthcare professionals involved in pain management, including pharmacists, therefore have a responsibility to help relieve pain and suffering for the best possible patient outcomes and for the good of the greater medical community.3,4

Effective pain treatment involves a multidisciplinary, personalized, and often multimodal effort, and having pharmacists on a pain treatment team has been associated with better pain symptom control. As medication experts, pharmacists play a crucial role in facilitating patient access to pharmacological analgesics,5,6 making their clinical skills in pain management—and those of pharmacy managers—of the utmost importance.1

Many factors encumber pharmacists’ participation in pain management, however, including regulatory issues, documentation difficulties, fear of regulatory scrutiny and reprisal from state and federal authorities, fear of promoting addiction, limited training in pain control,7,8 negative misconceptions about pain and its treatment,9 and the complexity of pain regimens. Additionally, pharmacists’ limited knowledge pertaining to pain, pain management, and the addiction, physical dependence, or tolerance to medications, also plays a significant role.1,3,4,7,8,10,11 Further, pharmacists may be viewed as a hindrance to patients’ legitimate access to controlled substances for pain management,7 resulting in inadequate pain relief. These factors alone or combined may compromise pharmacists’ willingness to dispense even valid prescriptions for controlled substances to patients suffering from acute or chronic pain and thereby reduce pharmacists’ involvement in the pain management continuum.

The Need for Research on this Group

Most studies in the available literature on pain management involving pharmacists have been undertaken primarily in the inpatient setting and focused on cancer-related pain. Few studies have been conducted in the outpatient setting and even fewer have involved community pharmacists.7 The authors conducted a study to evaluate the knowledge of and attitudes toward pain management among pharmacists based in the state of Virginia. Specific objectives were to:

Identify pharmacists’ perceived barriers and factors that may contribute to suboptimal pain management.

Study Setup

The cross-sectional study used a mail survey to collect data from 1,000 community and hospital pharmacists practicing in Virginia. The study protocol was submitted for approval to the Virginia College of Osteopathic Medicine’s Institutional Review Board (IRB). Data were collected through a mail survey instrument with a total of 30 items. The instrument was designed based on the existing literature on the subject and was divided into three main: attitudes toward pain and pain management, general practice issues/information, and demographic characteristics.

A survey was pilot-tested on a convenience sample of five hospital and community pharmacists in Southwest Virginia; necessary changes were made to the survey based on this feedback results. Next, a random sample of 1,000 active pharmacists was drawn from a Virginia Pharmacists Association list of licensed Virginia pharmacists. Only registered and currently active pharmacists practicing pharmacy in the state of Virginia were included in the study. Pharmacists working in community (independent, chain, clinic and other), long-term care, and hospital pharmacies were included.

A survey packet including a cover letter explaining the purpose of the project and a self-addressed postage paid questionnaire was mailed to each of the 1,000 pharmacists, with request for a two-week turnaround. Initial surveys were mailed in the winter of 2013 and spring of 2014 and questionnaires were collected over a six-week period.

In addition to sharing their gender, age, ethnic/racial background, job title, type of practice (retail-independent, retail-chain, hospital-independent, hospital-chain, other), size and setting of practice (inner city/city/suburban/rural), years of experience, hours worked, and number of prescriptions/medication orders dispensed per day, survey respondents had the opportunity to provide comments about the practice of pain management (see Table I). They were also asked to address whether they faced any impediments in attaining good pain management for their patients and whether their job required them to collaborate with hospice.

Analysis and Results

Data analysis was conducted using PASW Statistics Software (SPSS), with means, standard deviations, and frequency distributions computed for all variables. A p value of α < 0.05 was used for statistical significance. Correlation analyses examined whether the pharmacists’ age, years of experience, and hours worked were related to the attitude level (ranging from “strongly disagree” to “strongly agree,” see Table I) of the pharmacist. An independent groups t-test examined the differences in attitude scores between male and female pharmacists as well. Analysis of variance (ANOVA) was used to determine whether attitude levels differed by ethnic and racial background, job title, type of practice setting, and size/setting of employment of the pharmacist.

Demographics

A total of 147 responses were obtained for a 14.7% (147/1,000) response rate. Most respondents were female (n = 83; 56.5%), Caucasian (n = 119; 81.5%) and worked in retail chain stores (n = 76; 51.7%). The average age of the participating pharmacists was 51.9 (SD = 12.1) years. On average, pharmacists had practiced pharmacy for 26.2 (SD = 12.6) years.

On Opioids in their Practice/Community

Most pharmacists (n = 111, 75.5%) believed that diversion and abuse of prescription opioid analgesics was a problem in their community. A total of 122 pharmacists (83.0%) believed that the problem of diversion and abuse of prescription opioid analgesics was serious or very serious. The pharmacists’ perceived level of risk of opioid addiction in the community was high. Sixty-six percent (n = 96, 65%) rated the level of opioid addiction risk in their community as high or very high. The rest of the pharmacists rated it as low or not a problem (n = 49, 34%).

On Their Understanding of Controlled Substances

Sixty-nine percent (n = 101) of responding pharmacists rated the adequacy of their pharmacy education on controlled substances and pain management as being good or excellent (see Table II). A total of 23 (15.6%) pharmacists reported being concerned about being investigated or audited by a regulatory agency in regard to controlled substances matters (see Table III). Eighteen (12.2%) pharmacists had been investigated or audited by a regulatory agency in regard to controlled substances matters in the past.

Discussion

In this cross-sectional survey, the majority of responding pharmacists believed that diversion and abuse of prescription opioid analgesics was a problem in their community. In addition, they felt this problem was either serious or very serious, and many perceived the level of risk of opioid addiction in their community as high. These perceptions may make Virginia pharmacists apprehensive toward dispensing pain medicines as reported elsewhere,12 and may compromise patient care. For example, another study found that pharmacists overestimated the risk of addiction in patients who have pain.12

Some pharmacists believed that their knowledge of controlled substances was inadequate while others rated their knowledge of pain management as poor. Only a few pharmacists rated their level of knowledge in this area as excellent. More so, there was wide variation in pharmacists’ perceived knowledge.

Related Research

An older study found that effective pain management is achievable when pharmacists and other healthcare providers have sound knowledge on pain and its treatment.13 Doorenbos, et al. reported pain management training to be inadequate based on research conducted at the University of Washington with only 2% of total pharmacy curriculum time (124 credit hours) covering pain topics.14 Similarly, a recent poster presentation analyzing pain education deficiencies in pharmacy students revealed that the number of total didactic hours devoted to pain education varied from 0 (1%), 1 to 2 hours (17%), 3 to 4 hours (41%), up to or greater than 4 hours (41%).15 Previous studies have demonstrated that pharmacists had limited knowledge pertaining to pain, pain management, addiction, drug dependence, and drug tolerance.1,3,4,7,8,10,11 Recent work by Thomas and Muzyk showed increased didactic teaching related to substance use disorders (SUD) in the US pharmacy curricula, 16 specifically an increased from 81% of programs on how to manage SUD in 2004, to 94% and 2.7 hours in 2014-2015.16

Potential Impact

While certain curricular improvements have been identified and others are likely in process, more robust enhancements may still be needed as limited knowledge of pain management may compromise pharmacists’ effectiveness and reduce their willingness to participate in the pain care spectrum. Inadequate knowledge may also heighten fear about the risk of addiction. More importantly, a lack of education in this area may serve as a deterrence to patients’ legitimate access to controlled substances for pain management,7 resulting in inadequate pain management. More can and should be done to increase pharmacists’ knowledge of pain management and controlled substances. More research should be conducted to further identify the knowledge gaps related to pain management and substance abuse so that future educational programs may be better tailored to meet practicing pharmacists’ needs.

Survey results further demonstrated that many pharmacists did not believe the current legal requirements for prescribing, dispensing, and managing controlled substances have had a positive effect on preventing misuse, abuse, or diversion. Despite the perceptions reported, pharmacists and other healthcare providers have many tools at their disposal to ensure patient safety in utilizing controlled medications. These tools include, for example, prescription drug monitoring programs, urine drug monitoring, pill counts, collaborative care approaches, and routine follow-up.

Study Limitations

Several study limitations should be considered when evaluating the findings presented. First, only about 15% of the sample responded. Consequently, nonresponse bias may be a concern and the generalizability of the study may be limited. Second, no data were available on the psychometric properties of the survey employed in this study, however, the instrument has been used widely.

Conclusion

A significant number of responding pharmacists indicated that they had less than “good” knowledge of pain management. More needs to be done to educate pharmacists about pain treatment, including the use of controlled substances, especially considering the recent wave of regulatory and practice changes related to pain management.

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